Pilot Debrief

BEECH A36 near Avalon, CA — 2009-02-06

Final reportWPR09FA112
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Date
2009-02-06
Location
Avalon, CA, USA
Airport
AVX
Aircraft
BEECH A36
Registration
N66819
Category
Airplane
Highest injury
Fatal
Fatalities
3
Phase of flight
Initial climb

Probable cause

The pilot’s failure to follow the published instrument departure procedures during the climb to cruise, and loss of control in instrument meteorological conditions. Contributing to the accident was the pilot’s lack of total experience in instrument meteorological conditions.

Contributing factors

Contributing to the accident was the pilot’s lack of total experience in instrument meteorological conditions.

NTSB narrative

A witness observed the airplane lift off at midfield, then climb straight ahead and enter the clouds. The witness said that the winds were strong and gusty; it was clear to the north and east. A special aviation routine weather report (METAR) for the departure airport was issued at 1630. It stated that the winds were from 210 degrees at 16 knots gusting to 26 knots; visibility was 6 miles with mist. The skies were 200 feet broken, and 700 feet overcast. The temperature and dew point were both 11 degrees Celsius. The departure airport has a field elevation of 1,602 feet mean sea level; the VORTAC navigational unit is 171 degrees at 1.8 nm from the airport. The elevation of the VORTAC is 2,090 feet. The published instrument flight rules departure procedure from the airport for both runways 4 and 22 was to climb straight ahead to 2,300 feet, and then proceed on course. The pilot filed for direct to the VORTAC, direct to another location and then to the destination airport at 3,000 feet. Recorded radar data indicated the airplane made a 90-degree climbing left turn at 1,800 feet at the departure end of runway 22. Over the next couple of minutes, it turned left, then back toward the original course. It then made a 180-degree right turn, and reached a peak altitude of 2,400 feet. At some points during the maneuvering it was less than 400 feet above ground level. The airplane then began a descending left turn that reached descent rates of 4,000 feet per minute. The last target for the airplane was at an altitude of 1,800 feet and about 1/4 nautical mile (nm) from the accident site. The site was 175 degrees at 1.6 nm from the center of the airport, and was about 1/4 nm northwest of the VORTAC. The wreckage was in hilly terrain, and the airplane appeared to impact the ground in a level upright attitude. The debris path began near the mouth, and on the right side slope, of a canyon; it continued up the canyon toward rapidly rising terrain. The pilot had fewer than 400 hours total time, and fewer than 15 hours actual instrument time. Postaccident examination of the airframe and engine revealed no anomalies that would have precluded normal operation.

Analysis

Primary failure mode
Loss of control
First missed decision gate
Pilot did not check weather before departure despite IFR conditions.

NTSB coding

Evidence available

  • ADS-B / radar
  • Photos
  • 31 docket documents
View NTSB final reportView NTSB docket

Docket documents31

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